Accelerometer Measurements Indicate That Arm Movements of Children With Cerebral Palsy Do Not Increase After Constraint-Induced Movement Therapy (CIMT)

Filtering walking actigraphy data in children with unilateral cerebral palsy: A preliminary study

This study aimed to determine whether filtering out walking-related actigraphy data improves the reliability and accuracy of real-world upper extremity activity assessment in children with unilateral cerebral palsy. Twenty-two children aged 4-12 years diagnosed with unilateral cerebral palsy were included in this study, which was drawn from a two-phase randomized controlled trial conducted from July 2021 to December 2022. Data were collected from a tertiary hospital in Seoul, Republic of Korea. Participants were monitored using tri-axial accelerometers on both wrists across three time points (namely, T0, T1, and T2) over 3 days; interventions were used between each time point. Concurrently, an in-laboratory study focusing on walking and bimanual tasks was conducted with four participants. Data filtration resulted in a reduction of 8.20% in total data entry. With respect to reliability assessment, the intra-class correlation coefficients indicated enhanced consistency after filtration, with increased values for both the affected and less-affected sides. Before filtration, the magnitude counts for both sides showed varying tendencies, depending on the time points; however, they presented a consistent and stable trend after filtration. The findings of this research underscore the importance of accurately interpreting actigraphy measurements in children with unilateral cerebral palsy for targeted upper limb intervention by filtering walking-induced data.

Identifying the most representative actigraphy variables reflecting standardized hand function assessments for remote monitoring in children with unilateral cerebral palsy

BACKGROUND

Accurate assessment of physical activity and motor function in children with cerebral palsy is crucial for determining the effectiveness of interventions. This study aimed to investigate the correlation between real-world activity monitoring outcomes and in-laboratory standardized hand function assessments in children with unilateral cerebral palsy.

METHODS

Actigraphy data were collected over 3 days from children aged 4-12 years with unilateral cerebral palsy before in-laboratory assessments. To tackle the high dimensionality and collinearity of actigraphy variables, we first applied hierarchical clustering using the Pearson correlation coefficient as the distance metric and then performed a principal component analysis (PCA) to reduce the dimensionality of our data.

RESULTS

Both hierarchical clustering and PCAs revealed a consistent pattern in which magnitude ratio variables (ln[affected side magnitude/less-affected side magnitude]) were more strongly associated with standardized assessments of hand function than with activity time and distance domain variables. Hierarchical clustering analysis identified two distinct clusters of actigraphy variables, with the second cluster primarily consisting of magnitude ratio variables that exhibited the strongest correlation with Melbourne Assessment 2, Pediatric Motor Activity Log, Assisting Hand Assessment, and Manual Ability Classification System level. Principal component 2, primarily representing the magnitude ratio domain, was positively associated with a meaningful portion of subcategories of standardized measures, whereas principal component 1, representing the activity time and distance component, showed limited associations.

CONCLUSIONS

The magnitude ratio of actigraphy can provide additional objective information that complements in-laboratory hand function assessment outcomes in future studies of children with unilateral cerebral palsy. TRIAL REGISTRATION IN CLINICALTRIALS.GOV: NCT04904796 (registered prospectively; date of registration: 23/05/2021).

A Training Program Using Modified Joystick-Operated Ride-on Toys to Complement Conventional Upper Extremity Rehabilitation in Children with Cerebral Palsy: Results from a Pilot Study

The pilot study assessed the utility of a training program using modified, commercially available dual-joystick-operated ride-on toys to promote unimanual and bimanual upper extremity (UE) function in children with cerebral palsy (CP). The ride-on-toy training was integrated within a 3-week, intensive, task-oriented training camp for children with CP. Eleven children with hemiplegia between 4 and 10 years received the ride-on-toy training program 20-30 min/day, 5 days/week for 3 weeks. Unimanual motor function was assessed using the Quality of Upper Extremity Skills Test (QUEST) before and after the camp. During ride-on-toy training sessions, children wore activity monitors on both wrists to assess the duration and intensity of bimanual UE activity. Video data from early and late sessions were coded for bimanual UE use, independent navigation, and movement bouts. Children improved their total and subscale QUEST scores from pretest to post-test while increasing moderate activity in their affected UE from early to late sessions, demonstrating more equal use of both UEs across sessions. There were no significant changes in the rates of movement bouts from early to late sessions. We can conclude that joystick-operated ride-on toys function as child-friendly, intrinsically rewarding tools that can complement conventional therapy and promote bimanual motor functions in children with CP.

Referent data for investigations of upper limb accelerometry: harmonized data from three cohorts of typically-developing children

Aim

The rise of wearable sensing technology shows promise for addressing the challenges of measuring motor behavior in pediatric populations. The current pediatric wearable sensing literature is highly variable with respect to the number of sensors used, sensor placement, wearing time, and how data extracted from the sensors are analyzed. Many studies derive conceptually similar variables via different calculation methods, making it hard to compare across studies and clinical populations. In hopes of moving the field forward, this report provides referent upper limb wearable sensor data from accelerometers on 25 variables in typically-developing children, ages 3-17 years.

Methods

This is a secondary analysis of data from three pediatric cohorts of children 3-17 years of age. Participants (n = 222) in the cohorts wore bilateral wrist accelerometers for 2-4 days for a total of 622 recording days. Accelerometer data were reprocessed to compute 25 variables that quantified upper limb movement duration, intensity, symmetry, and complexity. Analyses examined the influence of hand dominance, age, gender, reliability, day-to-day stability, and the relationships between variables.

Results

The majority of variables were similar on the dominant and non-dominant sides, declined slightly with age, and were not different between boys and girls. ICC values were moderate to excellent. Variation within individuals across days generally ranged from 3% to 32%. A web-based R shiny object is available for data viewing.

Interpretation

With the use of wearable movement sensors increasing rapidly, these data provide key, referent information for researchers as they design studies, and analyze and interpret data from neurodevelopmental and other pediatric clinical populations. These data may be of particularly high value for pediatric rare diseases.

An Exploration of Tri-Axial Accelerometers in Assessing the Therapeutic Efficacy of Constraint-Induced Movement Therapy in Children with Unilateral Cerebral Palsy

This study aimed to elucidate the role of tri-axial accelerometers in assessing therapeutic interventions, specifically constraint-induced movement therapy (CIMT), in children with unilateral cerebral palsy (UCP). The primary focus was understanding the correlation between the actigraphy metrics recorded during CIMT sessions and the resultant therapeutic outcomes. Children with UCP, aged between 4 and 12 years, participated in this study from July 2021 to December 2022. In conjunction with in-clinic sessions, during which participants wore tri-axial accelerometers on both limbs, we analyzed actigraphy data over three days of routine activities pre- and post-CIMT. While not all metrics derived from the accelerometers indicated significant improvements post-intervention, there was a clear trend towards a more balanced usage of both limbs, particularly evident in Axis 3, associated with vertical movement (p = 0.017). Additionally, a discernible correlation was observed between changes in the magnitude ratio derived from actigraphy data during CIMT (Δweek3-week1) and variations in traditional assessments pre- and post-intervention (ΔT0-T1), specifically the Assisting Hand Assessment grasp and release. Using tri-axial accelerometers has helped clarify the potential impacts of CIMT on children with UCP. The preliminary results suggest a possible link between actigraphy metrics taken during CIMT and the subsequent therapeutic outcomes determined by standardized tests.

Bimanual Movement Characteristics and Real-World Performance Following Hand-Arm Bimanual Intensive Therapy in Children with Unilateral Cerebral Palsy

The purpose of this study was to quantify characteristics of bimanual movement intensity during 30 h of hand-arm bimanual intensive therapy (HABIT) and bimanual performance (activities and participation) in real-world settings using accelerometers in children with unilateral cerebral palsy (UCP). Twenty-five children with UCP participated in a 30 h HABIT program. Data were collected from bilateral wrist-worn accelerometers during 30 h of HABIT to quantify the movement intensity and three days pre- and post-HABIT to assess real-world performance gains. Movement intensity and performance gains were measured using six standard accelerometer-derived variables. Bimanual capacity (body function and activities) was assessed using standardized hand function tests. We found that accelerometer variables increased significantly during HABIT, indicating increased bimanual symmetry and intensity. Post-HABIT, children demonstrated significant improvements in all accelerometer metrics, reflecting real-world performance gains. Children also achieved significant and clinically relevant changes in hand capacity following HABIT. Therefore, our findings suggest that accelerometers can objectively quantify bimanual movement intensity during HABIT. Moreover, HABIT enhances hand function as well as activities and participation in real-world situations in children with UCP.

Outcomes Associated with a Single Joystick-Operated Ride-on-Toy Navigation Training Incorporated into a Constraint-Induced Movement Therapy Program: A Pilot Feasibility Study

Our research aims to evaluate the utility of joystick-operated ride-on-toys (ROTs) as therapeutic adjuncts to improve upper extremity (UE) function in children with hemiplegic cerebral palsy (HCP). This study assessed changes in affected UE use and function following a three-week ROT navigation training incorporated into an existing constraint-induced movement therapy (CIMT) camp in 11 children (3-14 years old) with HCP. We report changes in scores on the standardized Shriners Hospital Upper Extremity Evaluation (SHUEE) from pretest-to-posttest and changes from early-to-late sessions in percent time spent by the affected arm in: (a) "moderate-to-vigorous activity", "light activity" and "no activity" bouts based on accelerometer data and (b) "independent", "assisted", and "no activity" bouts based on video data. We also explored relationships between standardized measures and training-specific measures of affected UE activity. We found small-to-medium improvements in the SHUEE scores. Between 90 and 100% of children also showed medium-to-large improvements in affected UE activity from early-to-late sessions using accelerometers and small improvements via video-based assessments. Exploratory analyses suggested trends for relationships between pretest-posttest and training-specific objective and subjective measures of arm use and function. Our pilot data suggest that single joystick-operated ROTs may serve as motivating, child-friendly tools that can augment conventional therapies such as CIMT to boost treatment dosing, promote affected UE movement practice during real-world navigation tasks, and ultimately improve functional outcomes in children with HCP.

A protocol for a single-arm interventional study assessing the effects of a home-based joystick-operated ride-on-toy navigation training programme to improve affected upper extremity function and spontaneous use in children with unilateral cerebral palsy (UCP)

INTRODUCTION

Children with unilateral cerebral palsy (UCP) face significant limitations in upper extremity (UE) function and require effective interventions that promote intensive goal-directed practice while maximising motivation and adherence with therapy. This study builds on our past work and will assess the effects of a 6-week researcher-caregiver codelivered, home-based ride-on-toy navigation training (RNT) programme in young children with UCP. We hypothesise that the RNT programme will be acceptable, feasible to implement, and lead to greater improvements in unimanual and bimanual function when combined with conventional therapy, compared with conventional therapy provided alone.

METHODS AND ANALYSIS

15 children with UCP between 3 and 8 years will be recruited. During the 6-week control phase, participants will receive treatement-as-usual alone. During the subsequent 6-week intervention phase, in addition to conventional therapy, RNT will be provided 4-5 times/week (2 times by researchers, 2-3 times by caregivers), 30-45 min/session. We will assess UE function using standardised tests (Quality of Upper Extremity Skills Test and Shriner's Hospital Upper Extremity Evaluation), reaching kinematics, wrist-worn accelerometry, caregiver-rated ABILHAND-Kids questionnaire, and training-specific measures of movement control during RNT. Programme feasibility and acceptance will be assessed using device use metrics, child and caregiver exit questionnaires, training-specific measures of child engagement, and the Physical Activity Enjoyment Scale. All assessments will be conducted at pretest, following the control phase (midpoint), and after completion of the intervention phase (post-test).

ETHICS AND DISSEMINATION

The study is approved by the Institutional Review Board of the University of Connecticut (# H22-0059). Results from this study will be disseminated through peer-reviewed manuscripts in scientific journals in the field, through national and international conferences, and through presentations to parent advocacy groups and other support organisations associated with CP.

TRIAL REGISTRATION NUMBER

NCT05559320.

Time-matched accelerometers on limbs and waist in children with CP give new insights into real-life activities after botulinum toxin treatment: A proof of concept study

PURPOSE

This study aimed to explore the feasibility of using time-matched uniaxial accelerometers for measuring movement in daily life in children with cerebral palsy (CP) before and after botulinum toxin injections.

METHODS

This observational study of clinical care with a pre-post design was set in the home and school environment. Participants included eleven children (4-13 years of age) with CP (GMFCS I-III). The children wore uniaxial accelerometers (ActiGraph, model GT1M) for 4 days on both wrists, the right ankle and around the waist before, 3 weeks and 3 months after BoNT-A injections in the legs. Five children also got BoNT-A in the most affected arm. All injections were given according to clinical indications and routine. The accelerometers were all time-matched to define ambulation, arm swing, voluntary activity of arms, and bimanual activity. The feasibility of wearing accelerometers with this setup was evaluated. A linear mixed model was used for analysis of the percentage time and at which intensity the different activities were performed. The confidence interval demonstrated any difference between the dominant and non-dominant arm.

RESULTS

Time-matching of accelerometers placed on both wrists, the waist, and one ankle is a feasible method of registering ambulation, arm swing during gait, and arm movements while not ambulating. Before injections, the children spent 5.6% of their time ambulating. This value declined to 3.9% at 3 months. Contrary to clinical goals, arm movement did not increase after injecting the most affected arm with BoNT-A, however, injections may have decreased mirror movements, which are often bothersome for the child.

CONCLUSION

A time-matched 4-accelerometer set-up is feasible in children with cerebral palsy. A future study including time-matched multi-axial accelerometers on all four limbs, could provide important information on the effect of BoNT-A in daily life.

Accelerometry-Based Metrics to Evaluate the Relative Use of the More Affected Arm during Daily Activities in Adults Living with Cerebral Palsy

Adults living with cerebral palsy (CP) report bimanual and unimanual difficulties that interfere with their participation in activities of daily living (ADL). There is a lack of quantitative methods to assess the impact of these motor dysfunctions on the relative use of each arm. The objective of this study was to evaluate the concurrent and discriminative validity of accelerometry-based metrics when used to assess bimanual and unimanual functions.

METHODS

A group of control subjects and hemiplegic adults living with CP performed six ADL tasks, during which they were wearing an Actigraph GT9X on each wrist and being filmed. Four bimanual and unimanual metrics were calculated from both accelerometry-based and video-based data; these metrics were then compared to one other with an intraclass correlation coefficient (ICC). Some of these metrics were previously validated in other clinical population, while others were novel. The discriminative validity was assessed through comparisons between groups and between tasks.

RESULTS

The concurrent validity was considered as good to excellent (ICC = 0.61-0.97) depending on the experience of the raters. The tasks made it possible to discriminate between groups.

CONCLUSION

The proposed accelerometry-based metrics are a promising tool to evaluate bimanual and unimanual functions in adults living with CP.

3D Motion Capture May Detect Spatiotemporal Changes in Pre-Reaching Upper Extremity Movements with and without a Real-Time Constraint Condition in Infants with Perinatal Stroke and Cerebral Palsy: A Longitudinal Case Series

Perinatal stroke (PS), occurring between 20 weeks of gestation and 28 days of life, is a leading cause of hemiplegic cerebral palsy (HCP). Hallmarks of HCP are motor and sensory impairments on one side of the body—especially the arm and hand contralateral to the stroke (involved side). HCP is diagnosed months or years after the original brain injury. One effective early intervention for this population is constraint-induced movement therapy (CIMT), where the uninvolved arm is constrained by a mitt or cast, and therapeutic activities are performed with the involved arm. In this preliminary investigation, we used 3D motion capture to measure the spatiotemporal characteristics of pre-reaching upper extremity movements and any changes that occurred when constraint was applied in a real-time laboratory simulation. Participants were N = 14 full-term infants: N = six infants with typical development; and N = eight infants with PS (N = three infants with PS were later diagnosed with cerebral palsy (CP)) followed longitudinally from 2 to 6 months of age. We aimed to evaluate the feasibility of using 3D motion capture to identify the differences in the spatiotemporal characteristics of the pre-reaching upper extremity movements between the diagnosis group, involved versus uninvolved side, and with versus and without constraint applied in real time. This would be an excellent application of wearable sensors, allowing some of these measurements to be taken in a clinical or home setting.

Feasibility of using acceleration-derived jerk to quantify bimanual arm use

BACKGROUND

Accelerometers have become common for evaluating the efficacy of rehabilitation for patients with neurologic disorders. For example, metrics like use ratio (UR) and magnitude ratio (MR) have been shown to differentiate movement patterns of children with cerebral palsy (CP) compared to typically-developing (TD) peers. However, these metrics are calculated from "activity counts" - a measure based on proprietary algorithms that approximate movement duration and intensity from raw accelerometer data. Algorithms used to calculate activity counts vary between devices, limiting comparisons of clinical and research results. The goal of this research was to develop complementary metrics based on raw accelerometer data to analyze arm movement after neurologic injury.

METHOD

We calculated jerk, the derivative of acceleration, to evaluate arm movement from accelerometer data. To complement current measures, we calculated jerk ratio (JR) as the relative jerk magnitude of the dominant (non-paretic) and non-dominant (paretic) arms. We evaluated the JR distribution between arms and calculated the 50th percentile of the JR distribution (JR50). To evaluate these metrics, we analyzed bimanual accelerometry data for five children with hemiplegic CP who underwent Constraint-Induced Movement Therapy (CIMT) and five typically developing (TD) children. We compared JR between the CP and TD cohorts, and to activity count metrics.

RESULTS

The JR50 differentiated between the CP and TD cohorts (CP = 0.578 ± 0.041 before CIMT, TD = 0.506 ± 0.026), demonstrating increased reliance on the dominant arm for the CP cohort. Jerk metrics also quantified changes in arm use during and after therapy (e.g., JR50 = 0.378 ± 0.125 during CIMT, 0.591 ± 0.057 after CIMT). The JR was strongly correlated with UR and MR (r = - 0.92, 0.89) for the CP cohort. For the TD cohort, JR50 was repeatable across three data collection periods with an average similarity of 0.945 ± 0.015.

CONCLUSIONS

Acceleration-derived jerk captured differences in motion between TD and CP cohorts and correlated with activity count metrics. The code for calculating and plotting JR is open-source and available for others to use and build upon. By identifying device-independent metrics that can quantify arm movement in daily life, we hope to facilitate collaboration for rehabilitation research using wearable technologies.